1. Improving Patient Safety in the NHS
Sarah Tilford Improvement Manager Patient Safety NHS Improvement 2 November 2016

2. This session
To introduce the national vision for improving patient safety
To give a brief overview of our key work programmes
To illustrate how your collaborative work connects with the national safety improvement priorities

3. The NHS in 2016 Over 1 million patients every 36 hours
15.462m hospital admissions
£ bn planned net expenditure
In England:
- 155 acute trusts
- 56 mental health trusts
- 34 community providers
- 10 ambulance trusts
- c 8,000 GP practices
c 150,273 doctors
c 377,191 qualified nursing staff
1.4 Million make it possible

4. Great potential for error – the NHS in England

6. System pressures - access, targets , finance
Influencing Factors
System pressures - access, targets , finance
Human factors e.g. Slips / lapses
System design - fragmented /environmental
Organisation v patient centred
Cultural norms or behaviours
Leadership and teamwork
Transparency – ability to listen and learn from error or near misses

7. Improving the safety of patients in England
“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”
Professor Don Berwick

8. Patient Safety Vision for 2020
We want to support the NHS to become a system devoted to continuous learning and improvement of patient safety.
Increasing our understanding of what goes wrong in healthcare
Enhancing the capability and capacity of the NHS to improve safety
By tackling the major underlying barriers to widespread safety improvement

9. Understanding what goes wrong
Our two specific statutory duties apply to all NHS-funded care:
The responsibility for the National Reporting and Learning System
The responsibility for using that information to provide advice and guidance to the NHS ‘for the purposes of maintaining and improving the safety of the services provided by the health service’ (Health and Social Care Act 2012 part 1, section 23, clause 13R).

10. Patient Safety in NHS Improvement

11. The National Reporting and Learning System – 1
The National Reporting and Learning System – 1.8 m reports received annually
*’Patient abuse (by staff/third party)’ is mainly used for disclosure of abuse outside healthcare to healthcare staff.

12. NRLS outputs, including use by other key partners

13. Patient Safety in NHS Improvement

14. Patient Safety Collaboratives
15 collaboratives led with the innovation and expertise of the AHSNs
Each covers 2-5m population
5 AHSN jointly fund SoE MH collaborative
Locally owned and run
A unique opportunity only the NHS can bring as a single system
Largest collaborative patient safety programme in the UK
Stronger by learning together connecting and sharing
United around common themes e.g. sepsis

15. Longest running MH collaborative – since 2011
Mental Health Collaborative
Longest running MH collaborative – since 2011
Long history of learning and development across organisations
160 teams engaged in QI
Gained expertise and independence from IHI
Cost effective

16. South England MH Collaborative Impact
Good examples of progress and impact
50% reduction in AWOL
23% reduction in prone restraints
46% reduction in seclusion incidents
85% reduction in self harm incidents in 1 ward
Executive teams engaged - resolving problems & hearing concerns

17. Collaborative effort – keep going
Focus on local safety concerns in your sector
Develop and test solutions and ideas
Lead implementation of evidence based safer care initiatives
Challenge the status quo
Develop approach adoption and spread (steal with pride)
Harness talents, listen and learn, keep patients at the centre of all you do
Build on your own QI / leadership capability
Increased connectivity, engage in networks - e.g. Q, SU2S

18. 80% mental health + partnership trusts
Over 400 organisations
100% community providers
96% acute care
90% ambulance trusts
80% mental health + partnership trusts
28% CCGs
Five pledges; put safety first, be honest, continually learn, collaborate and be supportive

19. About Q
Diverse community of people working in improvement in health and care across the UK
Collaboratively designed with 447 members building to 5000 over 5 years
Make it easier for people leading improvement to share ideas, enhance their skills and make changes that bring improvements to health and care
Opportunities to join - for more details

20. Collective Focus for 16/17 Do more of what works well
Push adoption and spread - identifying key improvements of national significance
Scale up local projects, capture learning and share
Greater focus on
innovation in healthcare
strengthening Incident investigation and learning
leadership and capability building
measure impact and showcase success
Explore culture, behaviours, relationships and human factors

21. “Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love.”
Professor Avedis Donabedian

22. Relationships are key…

23. THANK YOU
@sarah_tilford